Last week, I discussed a rather execrable study. Actually, the study itself wasn’t so execrable, at least not in its design, which was a fairly straightforward three-arm randomized clinical trial. Rather it was the interpretation of the study’s results that was execrable. In brief, the authors tested an “energy healing” modality known as “energy chelation” versus a placebo (sham “energy chelation”) and found, as is so often the case in studies of “complementary and alternative medicine” (CAM) or “integrative medicine” (IM) that both modalities did better than no treatment on the primary outcomes but that the “real” treatment (if one can call energy chelation “real treatment”) produced outcomes that were statistically indistinguishable from the “sham” treatment. Not surprisingly, the next move on the part of the researchers was to do a bunch of comparisons, and, as is so often the case (particularly when one fails to correct statistically for multiple comparisons), they found a couple of secondary endpoints with barely statistically significant differences and trumpeted them as meaning that their “energy chelation therapy” has “significant promise for reducing fatigue.” They then argued that the study was also ” designed to examine nonspecific and placebo elements that may drive responses.”

Which brings us to the “power” of placebo.

As I was contemplating what I wanted to discuss this week, I thought about the study that Drs. Coyne, Johansen, and I objected to, but then I also thought about Dr. Crislip’s post last week and post I did about a month ago in which I noticed how lately CAM apologists seem to be—shall we say?—retooling their message in the wake of negative trial after negative trial of their implausible treatments. Gone (mostly) are claims of powerful specific effects and efficacy from treatments such as various “energy healing” modalities, acupuncture, homeopathy, and the like themselves, to be replaced by claims that physicians should embrace CAM because it’s “harnessing the power of placebo” to produce “powerful mind-body healing.” It’s a powerful message that has sucked in people who normally would be considered skeptics, such as Michael Specter, who, as I described, apparently bought into the message sufficiently that when Ted Kaptchuk was making the media round right before the holidays he happily published a fairly credulous interview with him entitled, The Power of Nothing: Could Studying the Placebo Effect Change the Way We Think About Medicine? (My answer: Very likely no.) Even Ira Flatow of Science Friday fell hard for Kaptchuk’s message, declaring at the beginning of the interview that Kaptchuk’s irritable bowel syndrome study is evidence that “placebos work even when patients are in on the secret.” (It’s not.)

That skeptics and scientists find the idea that the mind has the power to heal the body, often referred to as “self-healing” or “mind-body healing,” so seductive should probably not be surprising. After all, who wouldn’t want to be able to cure themselves simply by willing it to be so? It’s a concept that, like so many concepts in CAM, goes far back into ancient times and stretches forward to today in ideas like The Secret, which goes quite a bit beyond the whole idea of “mind-body healing” or healing yourself because you wish it to be so, and declares that you can have virtually anything you want simply by thinking the right thoughts. In fact, to me it appears that the “powerful placebo” is being drafted in the service of supporting what are, at their core, mystical beliefs far more than science. I’d like to elaborate on that idea a bit more than I did last time I discussed this isssue, where I concluded by writing:

In the end, all too much of the rebranding of CAM as placebo and the selling of placebos as some sort of powerful “mind-body healing” strikes me as being much like The Secret, in which wishing makes it so.

Let’s take a look at just how far this goes.

God and placebos

Late last week, a reader sent me an article from that wretched hive of scum and quackery, The Huffington Post, by a journalist named Robert Schiffman entitled How the Placebo Effect Proves That God Exists. I had thought to start out this post using Schiffman’s article as a sort of reductio ad absurdum demonstrating how far some people will go to ascribe supernatural powers to placebo effects, and, I must admit, it’s a tasty enough target to warrant a brief post of its own. In the context of my argument for this post, I think I’ll just “cherry pick” two passages from Schiffman’s argument:

The placebo effect is arguably the most underrated discovery of modern medicine. Replace “just the placebo effect” with “the amazing placebo effect,” “the mind boggling placebo effect.” To my way of thinking, the very existence of this mysterious effect proves that God exists. That’s right, you can find evidence for the foundational truths taught by religion in virtually every double blind medical research study!

Later, Schiffman exults:

Which brings us back to the placebo effect. It is mysterious, right? We don’t know how it happens. A person was sick and they take a sugar pill and next thing you know — voila — they are healthy. To call this “the placebo effect” is to dress up our ignorance in words. What has actually happened is nothing short of a miracle. Science has got no explanation for it– something immaterial (a thought?) has impacted something material (our body) in a way which utterly defies logic.

My citing Schiffman serves two purposes. First, I am using his arguments as an explicit example of how proponents of placebo medicine seem to view placebo effects as somehow supernatural or mystical; i.e., beyond “boring” normal human physiology made up of trillions of cells, each interacting with others and driven by thousands upon thousands of biochemical processes. In this case, Schiffman views placebo responses as “proof” that God exists! Second, it demonstrates a misunderstanding of placebo response common not just to CAM proponents, but to many other people and even all too many scientists, namely the misconception that placebo responses have any effect on the pathophysiology of disease. Schiffman, for instance, characterizes placebo responses explicitly as a sugar pill making a sick person healthy again, which to him is a phenomenon that is miraculous and without explanation. Of course, it would be nice to establish that such a phenomenon even exists in the first place, because certainly my reptilian pharma overlords would be very interested in being able to sell cheap sugar pills at a hugely inflated price in order to cure disease. The profit potential would be enormous!

Yes, I’m joking, but there is little doubt that people like Schiffman have a vastly inflated view of the power of placebo responses. Placebo responses are worth studying, to be certain, but unfortunately they are heterogeneous and derive from multiple factors, each of which contributes to observed responses in different proportions in different clinical situations. These include observation bias, regression to the mean, and differences in how patients perceive their symptoms, to name a few. Another problem with such an argument is that placebo doesn’t do anything to impact the pathophysiology of disease or conditions, and it’s often arguable whether it even impacts subjective symptoms all that much in many conditions, as Mark Crislip has emphasized to the point that he refers to the “placebo myth.” Unfortunately, in much the same way that Schiffman attributes placebo effects to God, CAM/IM advocates often ascribe near mystical powers to placebo, a sort of “mind over matter” or “mind over body” view that gives the happy but false impression that just by thinking happy, positive thoughts, you can have a major impact on your disease. Schiffman’s argument might be very obviously over-the-top, but at its core it’s not really different than a lot of arguments I see in favor of “harnessing the power of placebo.”

The fantastical power of willpower placebo

As comical as Schiffman’s argument is, he’s not alone in making some version of it. It’s just that, being more “spiritual” than religious, many CAM advocates don’t refer to the mystical force they believe to be behind placebo effects as God. Further evidence of prevalence of the viewpoint that we can heal ourselves solely with our minds comes from a post by Andre Evans entitled Proof that Your Own Thoughts and Beliefs Can Cause Self-Healing. In this post, Evans cites placebo effects as “evidence” that, if you just think about it hard enough, you can “heal yourself” of almost anything:

Numerous studies abound on the nature of the mind-body relationship, and how your mind can affect your biological functions. Much like how a hypochondriac may convince himself that he is sick, and subsequently ‘find’ (or make up) symptoms of his illness, a negative or even apathetic mindset may induce you into a lesser state of health. Conversely, having a generally positive disposition or outlook with regards to your health may actually make you healthier.

In clinical studies where patients are given placebos, they often will respond positively to them due to the expectation that they are receiving some form of beneficial medicine. Although not talking about placebo sugar pills specifically, this kind of self-treatment can be seen in one case where a woman’s own thoughts made her lose nearly 112 pounds.

Evans concludes:

The power of the mind is immense. Its influence can literally bend reality to match its perspective. You can often influence a situation more by thinking about it meticulously, as opposed to simply acting. If you believe something to be true, you will conform the world around you to match this expectation.

If you believe that your illness is getting worse, it will probably get worse. If you believe that your treatment is helping you, you could actually cause massive self-healing to occur. Assuming a disposition will automatically prejudice your mind, and therefore cause your body to react either positively or negatively.

The influence of the mind can “literally bend reality to match its perspective”? Note that Evans doesn’t mean this figuratively. Oh, no. He means it literally. The only way to describe this viewpoint is pure magical thinking, a mystical, religious belief that, if you only have enough faith, you can have whatever you want and you can heal yourself. Would that it were so! Unfortunately, it’s not. Sure, having a positive attitude can make one feel better about his or her situation, and having a negative attitude can sometimes get in the way of doing what needs to be done to treat a condition, but it’s a huge exaggeration to claim that the mind can “literally bend reality” to match its perspective. If that were the case, why can’t I bend reality to guarantee that I live to 120? Or why can’t I “bend reality” to make myself a billionaire? Why can’t I think my way to having the body of 25-year-old again? This sort of thinking is at the level of a three or four year old, who can’t always tell the difference between fantasy and reality. Normally, we grow up; CAM/IM thought of this sort strikes me as a severe case of arrested development.

People often think I’m exaggerating when I speak of CAM advocates arguing extreme versions of “mind over matter.” I used to think that no one could make such arguments seriously, but I learned a long time ago that I was wrong in that assessment. If you don’t believe how far this thinking goes in a lot of CAM, I think it’s instructive to show you an example from–who else?–the quack apologist supreme, Joe Mercola, who a few years ago wrote a post entitled How your thoughts can cause or cure cancer. Mercola, as he so often does, starts out with a video:

This video, not surprisingly, is chock full of misinformation. For instance, it claims that no cancer gene has ever been found. Really? How about BRCA1 and BRCA2? Or BRAF mutations? Or one of a number of oncogenes and tumor suppressors that have been discovered in the last 40 years? Admittedly, it turns out that cancer is much more complicated than what we originally thought in that individual genes are usually (but not always) the cause and that there is not usually a straight progression of genes that are mutated in order to result in cancer progression. This is the primary reason why cures for most cancers that can’t be cut out surgically have proven elusive, with leukemias and lymphomas being exceptions to this rule. However, that is an entirely different thing than there being no cancer genes. It also uses and abuses the concept of epigenetics (the regulation of gene expression by factors other than the genome, such as methylation of genes,chromatin structure, and other things that can regulate DNA structure and function) to claim that cancer is “optional–not determined by genetics, nor an unavoidable fact” and that “your mind, your beliefs–not defective genes–create a ripple effect that ‘turns on’ cancer cells.”

Apparently, if Mercola is to be believed, your mind is apparently so powerful that it can control the expression of oncogenes and tumor suppressors to result in cancer. According to this view, your “genetic blueprint” is not the problem” but rather “how your cells interpret the directions of your mind.” In fact, this view even goes so far as to claim that spontaneous remissions of cancer are “tied to having a profound change in a perception or belief about life.” I kid you not. What this boils down to is the overarching claim that your mind can create disease and that, through the placebo effect, you can heal yourself. In fact, Joe Mercola makes explicit what is stated in the video:

Your beliefs are energy fields, and they are working to promote either health or disease in your body right now. Which one is up to you.

When it comes to the ability of your mind to heal you, there are NO limitations. The sky is the limit.

Got that? There are NO limitations! One wonders why if that’s true, amputees can’t think their way to growing a new limb. Yes, I know, it’s the same rationale behind the sarcastic question directed at faith healers, namely Why won’t God heal amputees? However, the question applies here just as well. If there are truly “no limits” to the power of the mind and if the mind can control epigenetics so profoundly, then it should be possible, through the mind directing the epigenetics of the cells at the end of the amputated stump, to reprogram the cells to become embryonic stem cells again and then to grow and differentiate into the cells necessary to regenerate a new limb, just like a salamander. The genetic blueprint is there; the genetic program to turn a cell back into a stem cell is just dormant and can be reactivated. Indeed, how to do that is one of the hottest areas of biomedical research right now. So, if all it takes is changing the gene expression of a cell, then why can’t we think our way to new limbs? Unfortunately, we never see a person thinking himself a new limb. There are other examples. For instance, if there are “no limits” to what the mind can do, why can’t patients in end stage organ failure do a little epigenetic programming and regenerate and thereby repair the failing organ?

Yes, yes, I know. It’s difficult. So difficult that no case of limb regeneration due to thought alone has been reported, nor has a case of someone thinking their way to a new organ.

However, there is something you should know. Other people can influence your perception of things and ultimately your ability to express your true beliefs.

So, perhaps you feel thrilled to have learned this information, but when you share it with your spouse or coworkers, they will not feel the same way. Their negativity could then easily transfer to you and cause you to doubt your mind’s healing abilities (thus making your mind unable to manifest healing).

You heard it right. All those negative vibes of skeptics are what’s standing between you and the ability to think your way to perfect health! I can’t help but find it highly ironic in light of Mercola’s statement that the investigators who did that misbegotten trial of “energy chelation” I described last week chose a control group in which:

Mock healing practitioners were skeptical scientists who were trained to use the identical hand placements as biofield healing practitioners. Mock healing practitioners were asked not to intend to heal the patient when touching, but rather to disengage into “planning mind” by contemplating current and upcoming research-oriented studies and grants they were currently involved in.

I remind readers that there were no statistically significant difference in the primary outcomes of this trial; apparently for energy chelation and fatigue at least, the negative vibes from the skeptics failed to harsh the happy buzz from the good vibes from the energy chelation, mainly because there was no happy buzz from the good vibes from energy chelation to begin with! In any event, it is clear that even the investigators responsible for the “energy chelation” trial at some level must buy into a variant of the ideas above about “mind-body” effects. If they didn’t, they wouldn’t have decided upon the sham energy chelation therapy that they used for their control group.

Still don’t believe me? Then let’s take a look at what Oprah Winfrey says because, as we all know, if Oprah says it it must be true. In this case, Oprah is republishing an article by that guru of “quantum mind-body medicine” himself, Deepak Chopra:

Yet somehow, for all its complexity, the healing system can be triggered by a simple intention of the mind. To be your own placebo, then, requires the same conditions that apply in a classic placebo response:

You trust what is happening.

You deal with doubt and fear.

You don’t send conflicting messages that get tangled with each other.

You have opened the channels of mind-body communication.

You let go of your intention and let the healing system do its work.

But what does Chopra mean by the “mind”? When neuroscientists speak of the mind, they generally are referring to consciousness, which the evidence in neuroscience increasingly indicates is nothing more than a product of the function of the brain. If placebo effects are a real biological phenomenon and not just an artifact of clinical trial design (or, as Mark Crislip put it so amusingly, the beer goggles of medicine), they will work through biology. Yet infused in so many of these invocations of the “powerful placebo” is a solid core of Cartesian mind-brain dualism; i.e., the concept . Indeed, Deepak Chopra makes it explicit in another post he did for Oprah:

Just as a radio picks up the signals that transmit music, so the brain functions to bring mind into everyday reality. If the radio is smashed, the music goes away. If the brain is ill, defective or damaged, some aspect of mind will go away. But to use this reasoning as proof that the brain is the mind or more real than the mind, is utter folly.

Chopra concludes:

It’s my personal conviction that the brain was created by consciousness. There is no other viable explanation, because our current explanation, that the human brain evolved through random mutations, simply doesn’t hold water. Our brains are the single most complex structures in the universe. To say that they were randomly created is a million times more unlikely than having 10 monkeys sitting at typewriters produce all of Shakespeare. But that’s a topic for deeper thought. It will be good enough if coming generations turn back to the mind and stop reducing the richness of experience to a mushy machine made of meat.

Shorter Chopra: I don’t like how biology, evolution, and neuroscience have decreased my feeling of “specialness” and connection with the supernatural; so I reject scientists’ reality and substitute my own.

According to Brody, the placebo phenomenon–which he pronounces mysterious and unknowable at its very heart–is when the convergence of healing signals, assigned meaning, and human expectations stimulates the body’s inner healing power. The patient’s positive mental and emotional reaction to a medical intervention releases what Brody terms the “inner pharmacy.” In other words, even though the treatment is benign, the body’s biochemical pathways are stimulated to induce healing in the same manner actual medicines do. “Could harboring hope, faith, or expectation be genuinely potent factors in the healing process?” Brody asks, “I believe they are. In fact, I see them as the heart and soul of the placebo response.

In his editorial, Brody makes similar arguments, completely buying into Kaptchuk’s irritable bowel syndrome study that is touted as evidence that placebo effects can be induced without deception. His arguments are not explicitly dualistic, as Chopra’s are, but I do detect more than a few overblown claims for what placebos can do, and that’s even after his editorial was peer reviewed for inclusion in JAMA. I can only imagine what Brody writes in his book. That Brody was invited to write this editorial suggests that CAM-like ideas about placebo are infiltrating conventional medicine in a feedback loop in which CAM apologists see these sorts of articles and trumpet them as evidence that they are on to something and that medicine is finally coming around to their way of thinking. I fear they might be correct.

What placebo responses are not

Unfortunately, this sort of magical thinking pervades a lot of “alternative medicine,” just as it pervades The Secret. Such thinking is profoundly infantile in that it presumes that wishing makes it so, just as a child thinks that his thoughts make reality what he wants it to be. When you come right down to it, it’s a lot like religion. But what happens when the wish doesn’t work? What happens when wishing doesn’t make it so? What happens when mind doesn’t control matter? Blaming “negative energy” delivered by skeptics keeping you down only goes so far. There comes a time when you have no choice but to face reality. Even worse, as much as CAM apologists will labor mightily to deny it, there is a real undercurrent of blaming the victim in these ideas; i.e., it’s your fault if you get sick because you don’t think the right thoughts and/or it’s your fault if you’re not getting well because you don’t believe strongly enough, didn’t carry out the woo prescription closely enough, or—horror of horrors—you actually used standard-of-care chemotherapy to treat your cancer, thus contaminating your body and destroying any chance that faith-based treatments will cure you (and, of course, providing a convenient excuse when they fail). In reality, the sorts of extreme invocations of placebo effects made by Evans, Mercola, and Chopra are nothing more than old wine in a new bottle, in which vitalistic, dualistic beliefs are imposed on a known phenomenon (placebo responses) and used to conclude that magic works.

You can find this sort of thinking in reiki, which is basically faith healing substituting Eastern mysticism for Christianity; the so-called “German New Medicine,” which postulates that cancer and serious illness are due to “unresolved childhood trauma” and that you have to recognize and resolve such traumas in order to heal yourself; and Biologie Totale, which is the bastard offspring of the German New Medicine. All of these alt-med modalities postulate that disease is either a reaction to emotional trauma and that you can heal it with your mind. What is the whole area of “energy healing” but the idea that, if you just have enough faith, you can heal either yourself or others? Sure, alt-med enthusiasts gussy it up in language that co-opts (and corrupts) the concepts of epigenetics and placebo effects to make it seem as though anything is possible, but when you come right now to it, what we’re looking at is far more religious in nature than scientific. Maybe Kimball and I were closer than we thought when we referred to CAM and IM as the “new paternalism.”

Perhaps the must frustrating part of this “woo-ification” of placebo effects by CAM apologists is that the science of placebos is a fascinating topic that might actually have some potential applications in medicine. These applications would at the very minimum include how to design better clinical trials whose results are not confounded by placebo factors. At the most, however, they would involve understanding how neurochemical functions can affect a patient’s perception of his or her symptoms and using that understanding to maximize the effects of science-based interventions. One thing that is clear from a science-based standpoint is that these applications will not be the sorts of applications envisioned by the likes of Chopra and Evans, in which placebo effects are portrayed as some sort of healing “mind-body” magic. Indeed, notice the choice of terms, “mind-body.” Not “brain-body” or “nervous system-body,” which is in reality how placebo responses must, if they exist, work through mundane physiology and biochemistry given that the brain and nervous system are part of the body. No, their choice of the term “mind-body” is to me an implicit admission of the dualism and vitalism behind their “medicine.”

I keep hoping that the likes of Chopra, Mercola, and Evans do not succeed in completely co-opting placebo responses as a form of shamanistic magic, to be used as a primary force for healing. Unfortunately, I’m finding it harder and harder to be optimistic. How can I be when so many physicians appear to be not only ready to go back to the “good old days” of medical paternalism and placebo medicine under the guise of “empowering patients” to “heal themselves,” but to forget (or at least partially forget) the very foundations of science itself?